OF mental health care and mentally ill

Treatmenting post-traumatic stress disorder

Psychological debriefi ng is a single-session interview conducted immediately following a traumatic event intended to help those involved cope with their emotional responses to the trauma and prevent the development of PTSD. It involves encouraging the individual to talk through the event and their emotional reactions to it in a detailed and systematic manner. It is thought to aid integration of incident memories into the general memory system. Debriefi ng is now regularly offered following traumatic incidents, despite increasing questions about its effectiveness. Rose et al. (2002), for example, concluded from their meta-analysis of four well-conducted randomized controlled trials that debriefi ng may not only be ineffective in preventing PTSD, it can actually increase risk for the disorder. None of the studies they reviewed found a reduced risk for PTSD in the three to four months following the incident. The two studies that reported longer-term fi ndings found that those who received debriefi ng had nearly twice the risk of developing PTSD than those who did not receive the intervention. That is, debriefi ng seems to inhibit long-term recovery from psychological trauma. A number of explanations have been proposed for these fi ndings, although each remains speculative:

‘Secondary traumatization’ may occur as a result of further imaginal exposure to a traumatic incident within a short time of the event.

Debriefing may ‘medicalize’ normal distress, and increase the expectancy of developing psychological symptoms in those who would otherwise not have done so.

Debriefing may prevent the potentially protective responses of denial and distancing that may occur in the immediate aftermath of a traumatic incident. Although psychodynamic approaches have been used to some benefit with people with PTSD, the most frequently used interventions in the treatment of PTSD are based on cognitive behavioural principles.

Treatmenting post-traumatic stress disorder:Exposure techniques

The principles underpinning exposure methods in the treatment of PTSD are that the individual will ultimately benefi t from exposure to memories of the event and their associated emotions. The conditioning model suggests that distress lessens as the individual’s emotional response to these memories habituates over time. A more cognitive explanation is that exposure leads to reconciliation between memories and the meaning of the traumatic event and preexisting world schemata. Only by accessing and processing these memories will resolution occur. Trauma-focused CBT may lead to an initial exacerbation of distress as upsetting images, previously avoided where possible, are deliberately recalled.

To minimize this distress and to prevent drop-out from therapy, Leskin et al. recommended a graded exposure process in which the individual initially talks about particular elements of the traumatic event at a level of detail they choose over several occasions until they no longer respond with a stress response. Any new, and potentially more distressing, memories are avoided at this time, and become the focus of the next levels of intervention. Reactivation of memories by this procedure involves describing the experience in detail, focusing on what happened, the thoughts and emotions experienced at the time, and any memories that the incident triggered. This approach may be augmented by a variety of cognitive behavioural techniques, including relaxation training and cognitive restructuring. Relaxation may help the individual control their arousal at the time of recalling the event or at other times in the day when they are feeling tense or on edge. Cognitive restructuring may help them address any distorted cognitions they had in response to the event and make those thoughts less threatening (‘I’m going to die! . . . It felt like I was going to die, but actually that was more my panic than reality . . .’). Wells and Sembifocused on teaching people to minimize the rumination that can be a particularly distressing element of PTSD by using active distraction techniques. A number of studies have shown trauma-focused therapy to be superior to no treatment and alternative active interventions including supportive counselling and relaxation therapy without exposure. In one such study, Foa et al. randomly allocated female rape victims to either a waiting list control condition, self-instruction training, supportive counselling or an exposure programme. Participants in each of the active interventions evidenced greater gains than those in the waiting list condition. Immediately following the intervention period, participants in the self-instruction training condition fared best.

By threemonth follow-up, however, those in the exposure programme reported signifi cantly fewer intrusive memories and less arousal than participants in the other conditions. Similar results were reported by Marks et al. in a comparison of relaxation, exposure alone, cognitive restructuring alone, and exposure plus cognitive restructuring. By the end of the intervention phase, all he other treatments proved superior to relaxation, with no differences in effectiveness between them. By three- and six-month follow-up, the exposure programme proved superior. It seems that self-instruction and other cognitive techniques may help participants cope with the anxiety and other emotions evoked in the early stages of exposure programmes, while exposure to traumatic memories is critical to long-term benefit. The optimal treatment seems to involve a combination of self-instruction training or other cognitive strategies in the early stages of therapy combined with gradual exposure to traumatic memories. Treating people with PTSD may not require large amounts of specialist training. Gillespie et al. (2002) taught health care staff with minimal background in cognitive behavioural therapy how to provide an exposure-based intervention for PTSD in response to a large bomb which exploded in the small Northern Irish town of Omagh in 1998. Staff received a two-day workshop plus telephone contact with an expert in the treatment of PTSD and therapy supervision. The effectiveness of their intervention was similar to those reported in previous studies involving expert therapists.